Surgical management of pulmonary inflammatory pseudotumors: a single center experience

Diagnostic Performance of 18F-FDG Positron Emission Tomography/Computed Tomography and Blood Test Parameters for Pulmonary Inflammatory Pseudotumor

PURPOSE

Pulmonary inflammatory pseudotumor (PIP) is an inflammatory proliferative tumor-like lesion that frequently exhibits hypermetabolism on 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography imaging (PET/CT) and is readily misdiagnosed as a malignant tumor. The purpose of this study was to identify PIP by combining PET/computed tomography metabolic and blood test characteristics with machine learning.

PATIENTS AND METHODS

We recruited 27 patients with PIP and 28 patients with lung cancer (LC). The PET metabolic and blood test parameters were collected, and the differences between the groups were evaluated. In addition, we combined the support vector machine (SVM) classifier with the indicators that differed between the groups to classify PIP and LC.

RESULTS

For PET metabolic parameters, our findings showed that, as compared with the LC group, maximal standardized uptake value (P< 0.001, t = -4.780), Mean standardized uptake value SUVmean, P< 0.001, t = -4.946), and SD40% (P< 0.001, t = -4.893) were considerably reduced in the PIP group, whereas CV40% (P= 0.004, t = 3.012) was significantly greater. For blood test parameters, the total white blood cell count (P< 0.001, t= 6.457) and absolute neutrophil count (P< 0.001, t= 6.992) were substantially higher in the PIP group than in the LC group. Furthermore, the performance of SVM trained solely on PET metabolic parameters (mean area under the curve [AUC] = 0.84) was comparable to that of SVM trained solely on blood test parameters (mean AUC = 0.86). Surprisingly, utilizing the combined parameters increased SVM performance significantly (mean AUC = 0.98).

CONCLUSION

PET metabolic and blood test parameters differed significantly between the PIP and LC groups, and the SVM paradigm using these significantly different features has the potential to be used to classify PIP and LC, which has important clinical implications.

Post-COVID-19 Pulmonary Inflammatory Pseudotumors Treated With Steroid Taper

The aftermath of COVID-19 continues to unveil an array of pulmonary complications, extending beyond the acute phase of the viral infection. Among these emerging sequelae, we present the case of a 58-year-old individual who developed pulmonary inflammatory pseudotumors (PIPs) following recovery from COVID-19. PIPs are exceedingly rare benign lesions that can pose a diagnostic challenge due to their clinical and radiological resemblance to malignant neoplasms. Histologically, PIPs are characterized by a proliferation of myofibroblastic spindle cells accompanied by inflammatory infiltrates, including lymphocytes, plasma cells, and histiocytes. As our understanding of post-COVID-19 complications evolves, this case serves as the first exploration into the complex interplay between COVID-19 infections and the subsequent development of inflammatory pseudotumors. In this report, an investigation is performed into the clinical presentation, diagnostic challenges, and successful management of post-COVID-19 PIPs with a focus on the pivotal role of corticosteroid therapy in mitigating the inflammatory response associated with this unique post-viral entity and resolution of the masses.

Inflammatory Myofibroblastic Tumor of the Larynx: Report of a Case

PURPOSE

Inflammatory myofibroblastic tumor (IMT) is a rare tumor composed of mesenchymal myofibroblastic spindle cells enveloped by an inflammatory infiltrate. Historically, this tumor sparked debate regarding whether it was a true malignancy with metastatic potential or merely a locally destructive physiologic inflammatory response. Few reports of IMT exist in the recent literature, with the majority of cases occurring in the pediatric population and favoring the lungs. Here we present an exceedingly rare case of IMT involving the larynx of a 22-year-old female.

RESULTS

A hemorrhagic and solid mass of the right true membranous vocal fold was excised and sent for histopathological assessment. Features of the surgical specimens were diagnostic for IMT. Intralesional steroid therapy was selected for additional treatment. Panendoscopy facilitated surveillance for any additional or recurrent lesions, of which there were none. At 11 months post-excision, follow-up MRI revealed symmetric vocal cords without evidence of any masses.

CONCLUSIONS

Although rare, laryngeal IMT should be considered in any patient presenting with hoarseness due to a vocal fold mass. Based on the successful treatment of our patient, we suggest that our approach of surgical excision followed by intralesional corticosteroid injection may be an efficacious treatment approach for this rare tumor. However, more research is warranted to elucidate the most effective, safe, and cost-effective treatment approach.

Contrast-enhanced ultrasound (CEUS) - A new tool for evaluating blood supply in primary peripheral lung cancer

OBJECTIVES

To explore the feasibility of contrast-enhanced ultrasound (CEUS) as a new tool for characterizing vascularization of primary peripheral lung cancer.

METHODS

315 consecutive patients with definite primary peripheral lung cancers underwent CEUS examination from November 2016 to March 2022. CEUS parameters including time to enhancement (TE), time to peak (TP), time to wash-out (TW), distribution of vessels (DV), extent of enhancement (EE) and homogeneity of enhancement (HE) were obtained.

RESULTS

The lesions were grouped on the basis of TE which reflects tumor vascularization: early enhancement (pulmonary arterial vascularization) (n = 91) and delayed enhancement group (bronchial arterial vascularization) (n = 224). Overall, lung tumors commonly (71.1%) manifested a delayed enhancement which indicating blood supply originated from bronchial arteries, while an early enhancement was present in less than a third of the cases. Tumors with bronchial vascularization tended to show a delayed, reduced and heterogeneous enhancement. Correspondingly, it is characterized by a shorter TE, marked EE and a relatively infrequent occurrence of necrosis in tumors with pulmonary vascularization.

CONCLUSIONS

Providing micro-perfusion information, CEUS is a potentially imaging tool for evaluating blood supply in primary peripheral lung cancer.

Analysis of anatomical variations of the lingular artery of the left upper lobe using 3D computed tomography angiography and bronchography

Background

Thoracic surgeons must be familiar with the anatomy of the pulmonary artery during segmentectomy and segmentectomy. But pulmonary arteries have numerous variations and aberrant branching patterns. The purpose of the present study was to analyze the anatomical variations and frequencies of the lingular artery of the left upper lobe (LUL) using 3D computed tomography angiography and bronchography (3D-CTAB).

Methods

We retrospectively studied 166 patients having undergone lobectomy or segmentectomy from January to December 2020 at Fujian Medical University Cancer Hospital's Department of Thoracic Surgery. All patients underwent 3D reconstruction using 3D-CTAB before surgery.

Results

The lingular segment was supplied by 1 artery in 45.18% of cases, 2 arteries in 46.39% of cases, and 3 arteries in 8.43% of cases. The branching patterns of the lingular artery included 119 (71.68%) cases with interlobar origin, 35 (21.08%) cases with interlobar and mediastinal origin, and 13 (7.83%) cases with mediastinal origin. The interlobar lingular artery include superior lingular artery (A4) and inferior lingular artery (A5). The interlobar lingular artery type was A4a, A4b, A5 in 7.23% of cases; A4 and A4b+5 in 3.01% of cases; and A4b and A4a+5 in 4.82% of cases. The mediastinal lingular artery was divided into the following 5 types: 'A4', 'A4b', 'A4b+5', 'A4b+5a', and 'A4+5'. The most common type was A4 (12.05%, 20/166) in 166 patients. The interlobar lingular artery had the following 5 patterns of variation: 'A4+5', 'A4, A5', 'A4a, A4b, A5', 'A4a, A4b+5', and 'A4b, A4a+5'. The single interlobar lingular artery (A4+5) was the most common type in 38.55% of cases. In 24.10% of cases, A5 came from A8 or A8+9. Besides In 8.43% of cases, the origin of A5 was close to A8 or A8+9.

Conclusions

We identified the left various lingular artery branching patterns with 3D-CTAB in patients and defined the frequency of anatomic variations. 3D-CTAB is useful for finding these variations.

Clinical and pathological characteristics of patients with pulmonary inflammatory pseudotumors: An 18-year retrospective study of 31 cases

To investigate the clinical and pathological characteristics in patients with pulmonary inflammatory pseudotumors (PIP).This retrospective study included 31 patients with PIP from 2001 to 2019. Preoperative computed tomography scan was performed in all patients. Clinical and pathological characteristics were collected and analyzed.Thirty-one patients (16 female and 15 male) were recruited, with a median age of 57 years (range, 11-72 years). Eight (25.8%) patients were asymptomatic, and the others had symptoms characterized by cough with sputum, chest and back pain, dry cough, fever and blood in sputum, or hemoptysis. All cases were single lesions, including 23 cases in the right lung, and 8 cases in the left lung. Computed tomography scan demonstrated irregular lobulated nodules or masses in 14 patients, and regular round or oval nodules or masses in 11 cases. The blurred edge of tumors and spiculation was found in 12 cases. Microscopic results were characterized by the collection of inflammatory mesenchymal cells. Immunohistochemical examination showed vimentin, smooth muscle actin, and anaplastic lymphoma kinase positive. Complete tumor resection was obtained in all cases. No recurrence or metastasis was observed during the follow-up period.PIP has a variety of manifestations. Preoperative diagnosis is difficult to reach. The final diagnosis still depends on the pathological and immunohistochemical examination. Complete surgical resection is the main treatment at present, and the overall prognosis is good.

Unusual diagnosis in a patient presenting with fever and bilateral lung infiltrates

An 81-year-old former smoker, with a history of asthma and surgical treatment of abdominal aortic aneurysm, was admitted to hospital with a 1-month history of fever up to 38.6°C, purulent sputum and left-sided pleuritic chest pain. Chest computed tomography (CT) showed consolidation type infiltrates peripherally in both lungs. Flexible bronchoscopy revealed no endobronchial lesion and cytological and microbiological examination, as well as qualitative analysis of bronchoalveolar lavage (BAL) were non-diagnostic. The cytological examination of BAL revealed: macrophages 85%; lymphocytes 12%; eosinophils 2%; and other neutrophils 1%. Investigations for IgG4-related disease or any other autoimmune disorder were negative. The patient was treated with amoxicillin–clavulanic acid for 10 days before admission. He was treated with ciprofloxacin–clindamycin on admission, but due to clinical and radiological deterioration on chest CT, we administered wide-spectrum antibiotics (meropenem plus vancomycin) without clinically significant response (figure 1).

Inflammatory myofibroblastic tumour (IMT) is a rare neoplasm, most commonly described in children and young adults. We present a case of IMT in an elderly man. https://bit.ly/355wf8X

[Thoracic inflammatory pseudotumors : A rare differential diagnosis]

BACKGROUND

Inflammatory pseudotumors are a rare and in the main benign tumor entity but infiltrative growth, recurrence and metastases are described. Generally, a complete resection is needed to exclude lung cancer. This study analyzed our data and experiences with this rare tumor entity.

MATERIAL AND METHODS

We performed a retrospective study of all our patients who had been operated on between 2002 and 2016 in our institution for an inflammatory pseudotumor of the lungs. The extent of resection, morbidity, mortality and long-term results were analyzed.

RESULTS

Altogether, in this period 13 patients were operatively treated (5 women and 8 men). The median age was 52 years (range 34-74 years). A reoperation was carried out in one patient for recurrence after enucleation of the tumor in another hospital. In no case could lung cancer be excluded prior to complete resection. In total, 11 pulmonary, 1 tracheal and 1 chest wall pseudotumor could be resected by thoracotomy (9×) and thoracoscopy (3×) and 1 by ventral chest wall resection. In eight patients the resections were performed by standard resection (wedge resection or anatomic resection) and five times by extended resection. In all cases a R0 resection was achieved. Due to one case of postoperative pneumonia the morbidity and mortality rates were 7.7% and 0%, respectively.

CONCLUSION

The differential diagnosis between inflammatory pseudotumors and lung cancer cannot be definitely made preoperatively. For an exact diagnosis by the pathologist a complete histological preparation is needed. Due to infiltrative growth and recurrence, extended resection can be necessary for a R0 resection. This can be achieved with low morbidity and mortality. Important is an en bloc R0 resection, which is associated with good long-term results.

VATS segmentectomy: past, present, and future

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

A New Method for Discriminating between Bronchial and Pulmonary Arterial Phases using Contrast-Enhanced Ultrasound

This study aimed to explore the value of a real-time comparative observation method using contrast-enhanced ultrasound (CEUS) for discriminating between bronchial and pulmonary arterial phases in diagnosing lung diseases. Forty-nine patients with 50 pulmonary lesions (45 peripheral lesions and five central lesions with obstructive atelectasis, including 36 malignant tumors, five tuberculomas, four inflammatory pseudotumors and five pneumonia lesions) detected via computed tomography and visible on ultrasonography were enrolled in this study. The arterial phases were determined by comparing contrast agent arrival time (AT) in the peripheral lung lesion with that in adjacent lung tissue, referred to as a real-time comparative observation method. Detection rates of this observation method were 100% (50/50) for pulmonary arterial phase and 88% (44/50) for bronchial arterial phase. Using the instrument's built-in graphing and analysis software, a time-intensity curve was constructed based on a chosen region of interest within the lesion where enhancement was the most obvious. Commonly used perfusion indicators in CEUS, such as AT, time-to-peak and peak intensity, were obtained from the time-intensity curve. Percutaneous puncture biopsies were performed under ultrasound guidance, and specimens of all 50 lesions were examined pathologically. AT was significantly shorter in patients with pneumonia than in those with malignant tumors or chronic inflammation (p < 0.05), whereas no difference was seen between those with malignant tumors and those with chronic inflammation. No significant differences in time-to-peak or peak intensity were seen among those with various lung diseases (p > 0.05). This is the first description of a real-time comparative observation method using CEUS for determining the arterial phases in the lungs. This method is accurate, simple to perform and provides a direct display. It is expected to become a practical and feasible tool for diagnosing lung diseases.

Primary lung and large airway neoplasms in children: current imaging evaluation with multidetector computed tomography

Multidetector computed tomography (MDCT) offers an important noninvasive imaging modality for confirmation and further characterization of primary lung and large airway neoplasms encountered in pediatric patients. Children represent a unique challenge in imaging, not only because of unique patient factors (eg, inability to follow instructions, motion, need for sedation) but because of the technical factors that must be optimized to reduce radiation dose. This article reviews an MDCT imaging algorithm, up-to-date imaging techniques, and clinical applications of MDCT for evaluating benign and malignant primary neoplasms of lung and large airway in infants and children.

An Endobronchial Inflammatory Myofibroblastic Tumor Treated by Modified Left One-stoma-type Carinoplasty

Endobronchial inflammatory myofibroblastic tumor is a rare primary lung disease. A 39-year-old woman with dyspnea and a productive cough underwent complete surgical resection of a small-sized inflammatory myofibroblastic tumor that invaded the left main bronchus and the carina with lung-saving modified left one-stoma-type carinoplasty. We report this case with a review of literature.

Large pulmonary inflammatory myofibroblastic tumour requiring extrapleural pneumonectomy and diaphragm resection

Inflammatory myofibroblastic tumours are rare masses that account for a very small percentage of primary lung neoplasms. They are generally considered as benign tumours but can exhibit malignant characteristics. When identified, the mainstay of their treatment is complete surgical resection. We present a case report of a large pulmonary myofibroblastic tumour that required extensive resection to achieve complete clearance.